Empowering Our Futures Learning Academy LLC After School Program Registration Form
Fill out the form carefully for registration
Name of the person who referred you.
Parent/Guardian Full Name
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First Name
Middle Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Health Insurance?
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Yes
No
Insurance Provider
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Name of Policy Holder
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Subscriber ID/Group Number/Member Number
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Insurance Policy Ending Date
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Number of Children
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1
2
3
4
5
Child's Name
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First Name
Last Name
Child's sex
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Male
Female
Child's Date of Birth
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-
Month
-
Day
Year
Date
Grade Level
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Insurance Name
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Insurance Member Number
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Child's Social Security Number
*
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting/Aggression
Frequent Suspension
Health Concerns
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly Shy, Timid
Poor Communication Skills
Poor Motivation
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Other
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting/Aggression
Frequent Suspension
Health Concerns
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly Shy, Timid
Poor Communication Skills
Poor Motivation
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Other
Child's Name
First Name
Last Name
Child Sex
Male
Female
Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Insurance Name
Insurance Member Number
Social Security Number
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting Aggression
Frequent Suspension
Health Concerns
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly Shy, Timid
Poor Anger Management
Poor Communication Skills
Poor Motivation
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep/Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Child's Name
First Name
Last Name
Child Sex
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Insurance Member Number
Social Security Number
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting/Aggression
Frequent Suspension
Health Concerns
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly, Shy, Timid
Poor Anger Management
Poor Communication Skills
Poor Motivation
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep/Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Child's Name
First Name
Last Name
Child's date of Birth
-
Month
-
Day
Year
Date
Grade Level
Insurance Name
Insurance Member Number
Social Security Number
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting/Aggression
Frequent Suspension
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly Shy, Timid
Poor Anger Management
Poor Communication Skills
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep/Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Child's Name
First Name
Last Name
Child Sex
Male
Female
Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Insurance Member Number
Social Security Number
Reason for Service Needed (list all that apply)
Anxious
Argumentative
Bullying
Confused Thinking
Family Concerns/Conflict
Fighting/Aggression
Frequent Suspension
Health Concerns
History of Mental Health
Hostile/Defiant
Hyperactive, Inattentive, Impulsive
Withdrawn, Isolated
Obsession/Compulsion
Overly Shy, Timid
Poor Anger Management
Poor Communication Skills
Poor Motivation
Poor Social Skills
Sad, Tearful, Depressed
Self Harm
Sleep/Appetite
Substance Abuse
Suicidal/Homicidal Thoughts, Statements
Race
*
Ethnicity
*
Non Hispanic
Latino
Black/African American
Other
Primary Language Spoken At Home
*
Emergency Contact Name
*
Relationship
*
Doctor/Physician or Hospital Phone Number
*
Please enter a valid phone number
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor/Physician or Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload a copy of Insurance Card
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Authorization Forms
I authorize and give my consent for Empowering Our Futures Learning Academy LLC, to administer first aid to my child in the event of an emergency.
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I authorize and hereby give my consent for Empowering Our Futures Learning Academy LLC to collect photography and or videography for advertisement and promotional use only.
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As the parent or legal guardian with the authority to consent on behalf of the minor child listed below, I hereby give my consent for Empowering Our Futures Learning Academy LLC, and its affiliates to provide counseling/recreational play therapeutic behavioral services to my child.
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As a parent or legal guardian of the student, you have the right to grant or withhold permission for the release of your child's educational records to other individuals or agencies. This request provides you the opportunity to approve or deny such a release, except in situations where the release of records is permitted under exceptions established by the Family Educational Rights and Privacy Act (FERPA). For example, FERPA allows the transfer of records between school districts without prior consent. Please note that information obtained will be handled confidentially by the school district. The release of personally identifiable information without consent is restricted to limited circumstances under FERPA. If the requests pertains to health or medical records, such information received by the district is protected under FERPA, not the Health Insurance Portability and Accountability Act (HIPAA). This authorization is valid from the date signed below unless or until you withdraw your consent in writing. For medical records specifically, the authorization is valid for no more than 90 days after the date of signing. Withdrawal of consent will not affect the release of information that occurred under prior consent.
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General Permission and Legal Guardian Agreement Empowering Our Futures Learning Academy LLC (614)634-1506 eofla3@gmail.com, provides behavioral health services and programming. As the undersigned legal guardian, I hereby grant permission for my minor child (“Student”) to attend and utilize all programs and services offered by EOFLA. I understand that: 1. My child may attend EOFLA programs on any day and at any time the programs are in operation. EOFLA reserves the right to update its hours of operation, and I agree to any such revisions.2. EOFLA operates programs across various locations, and I consent to my child participating in programs at any current or future EOFLA location. 3. My child’s participation in EOFLA programs is a privilege and may be revoked at the sole discretion of EOFLA staff, with or without cause. 4. I agree to the terms, policies, and conditions outlined by EOFLA, which are available in the student handbook .I also grant permission for EOFLA to use photographs or videos of me or my child for promotional purposes, including in print, online publications, websites, presentations, or social media. I understand that I am not entitled to any royalties or compensation for such use.
General Assumption of Risk and Liability Waiver I acknowledge and understand the inherent risks associated with my child’s participation in EOFLA programs and use of EOFLA facilities, equipment, and services. In consideration of my child’s participation, I hereby: 1. Assume all risks, whether known or unknown, arising from my child’s participation in EOFLA activities.2. Waive, release, and discharge EOFLA, its affiliates, employees, agents, volunteers, and representatives from any liability or claims arising out of my child’s participation, including injuries, loss of property, or death.3. Agree to indemnify and hold EOFLA harmless from any claims or damages arising from my child’s activities or behavior.I understand that adherence to EOFLA policies, safety rules, and instructions from staff is mandatory for participation. Child Care and Student Record AuthorizationI, the undersigned parent or guardian, hereby authorize EOFLA and its affiliate programs to act on my behalf regarding the temporary care of my child under the following terms: 1. EOFLA staff may seek and authorize medical treatment in emergency situations. 2. EOFLA staff may excuse my child from school or pick up my child from school as necessary. 3. EOFLA staff may access and review my child’s academic records, including grades, attendance, and disciplinary records, for program-related purposes.This authorization is valid from the date signed and remains in effect until terminated in writing by the parent/guardian.
Consent for Services, I acknowledge and agree to the terms and conditions of therapy services provided by EOFLA, including compliance with policies related to confidentiality, record-keeping, telehealth, and in-person visits. I have reviewed the risks, benefits, and my rights as outlined in EOFLA Consent for Services. By signing this document, I confirm that I understand and accept all provisions contained herein. Here's an updated and refined version of the section with clear legal language, proper grammar, and the addition of HIPAA/health record release provisions
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Parent/Guardian Consent for Student Record and Health Information Release. As the parent or legal guardian of the student ("Student"), you have the right to approve or deny the release of your child's educational and health records to individuals or agencies. This request allows you to either provide consent or withhold consent for the release of such records unless permitted under an applicable exception outlined in the Family Educational Rights and Privacy Act (FERPA). For example, FERPA permits the transfer of records between school districts without prior consent. If the request pertains to health or medical records, it is important to note that such information is protected under both FERPA and, where applicable, the Health Insurance Portability and Accountability Act (HIPAA). FERPA governs educational institutions, while HIPAA may apply to medical providers or other entities that maintain health information. Authorization for Release of Records I understand that the release of my child's records, including but not limited to educational, attendance, disciplinary, and health records, will be handled in accordance with FERPA and HIPAA applies. This authorization is valid from the date of signature until such time as I revoke it in writing. I understand that if I choose to withdraw my consent, it will not affect records already released based on prior authorization. Additionally: •For health and medical records, this authorization is valid for no longer than 90 days from the date of signature unless otherwise specified.• Medical information released under this authorization may only be disclosed for the purposes outlined below. Permitted Disclosures Under HIPAA, I understand that, under HIPAA, my child's health information may be disclosed without my prior consent in certain situations, including but not limited to: 1. Medical Emergencies: To ensure the immediate health and safety of my child. 2. Mandatory Reporting: To comply with legal obligations, such as reporting abuse or neglect. 3. Public Health Requirements: For public health purposes, such as containing the spread of infectious diseases. Any use or disclosure of health information will comply with the minimum necessary rule, ensuring only the information required for the stated purpose is shared.
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General Conditions of Authorization by signing below, I acknowledge the following: 1. Voluntary Nature: I have the right to refuse authorization, and my refusal will not affect my child's ability to access educational services. 2. Revocation Rights: I may revoke this authorization at any time by providing written notice to the school district or Empowering Our Futures Learning Academy LLC.revocation does not apply to information already disclosed under prior consent. 3. Privacy Protection: I understand that any records released may not be further disclosed by the recipient without my explicit authorization unless otherwise permitted by law. Consent for Services Empowering Our Futures Learning Academy . By signing this document, I provide my consent for my child to attend EOFLA programs, receive related services, and participate in all approved activities. I acknowledge that my child's educational and health information, as necessary for service delivery, may be shared between EOFLA and its affiliates in compliance with FERPA and HIPAA. Authorization for Emergency Medical Treatment. In the event of a medical emergency, I authorize EOFLA and its designated representatives to secure medical treatment for my child. This includes contacting emergency medical services, consenting to medical procedures, and providing health records to treating providers as needed for the emergency. By signing this document, I certify that I have read and understand the above terms and authorize the release of my child's records as outlined.
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